By Nigel Dawes, M.A., L.Ac.

"This little piggy goes to market, this little piggy stays at home...."

The associations can remain remarkably vivid, even into adulthood, often evoking memories of excitement, anticipation, fear, and ultimately loss of control as we remember dissolving into a delirious state of ticklishness to the inevitable refrain of: "wee wee wee all the way home!". The sensation, though elicited voluntarily and in jest, not only shares some of the qualities of what we call "running piglet" in Chinese medicine but also, coincidentally perhaps, invokes the same image of the frantic, squealing little pig of which we will say more in a moment.

A quick informal survey amongst a dozen colleagues and students of mine recently revealed the following fairly unanimous but no less surprising responses to the question: "What do you know about running piglet syndrome?"

• Familiarity with the term though an inability to accurately describe its symptomology or identify clear treatment protocols.

• An awareness of its classical origins but identifying specific references to it in classical texts was problematic.

• An understanding of its pathomechanism as being related in some way to counterflow qi but a lack of clarity about specific differential diagnoses.

• A belief that a detailed appreciation of the diagnosis and treatment of running piglet is unnecessary in the modern clinic.

These findings appear to suggest that we, as clinicians, teachers, and students of Chinese medicine, are conversant with the term yet not so clear about what it actually means, from where it derives, and how best to treat it. But it was in response to the last finding, the apparent perception that familiarity with this ancient term and its manifestations no longer seemed relevant to the contemporary clinician, that I decided to write a short article based on my own experience of encountering and treating running piglet.

This article will serve as an introductory overture for my workshop on this topic at the PCOM symposium in November, 2009, and as a primer for two more detailed articles I am submitting for publication later this year in journals here and abroad. It is not my intention here to discuss Diagnosis and Treatment of this condition in any detail. I will reserve that for the workshop and subsequent articles. For now, I wish to identify the main presenting signs and symptoms of running piglet sources as well as entertain some of the possible mechanisms involved. Some contemporary English- language authors have already published useful material, though further research is needed on what I believe to be a widespread disorder particularly prevalent in high-stress, urban populations such as I encounter in my office. In particular, I will be presenting some of the Japanese Kanpo approaches to diagnosing and treating running piglet in the workshop, focusing especially on abdominal diagnosis and the application of appropriate classical formulas.

Origins, Definition & Mechanisms

Let's begin with two contemporary definitions of running piglet from leading authors in the field: "A sensation of qi rushing upwards from the lower abdomen to the chest, epigastrium, and throat. There will generally be concurrent pain discomfort, alternation of heat and cold, and palpitations."  "Qi is discharged and rushes up the penetrating channel [chong mai] causing great agitation and anxiety" and "rushes up to the throat with such ferocity that the patient feels he is close to death. It attacks and then remits". As to its classical origins, the term itself, Ben Tun Qi Bing first appeared in the Ling Shu Jing: "When the pulse of the Kidneys is slightly urgent...sometimes the accumulated qi of the Kidneys flares up to the region of the chest...." This passage clearly talks of symptoms originating in the lower abdomen (as confirmed by the Chi position pulse findings) and moving upwards towards the heart (or chest) area which includes the epigastrium.

In channel terms, this involves not only the trajectory of the Kidney channel itself (including its internal branch up to the throat) but also, inevitably, the Chongmai which originates in the "Kidneys" (aka. Uterus, lower abdomen) and travels up the core of the body, anterior to the spine, connecting uro-genital, reproductive, digestive, and circulatory organs and their respective functions. Not surprisingly, therefore, symptoms include abdominal pain and spasms, distention, belching, reflux, palpitations, shortness of breath, chest and throat constriction, and generalized anxiety. These are all characterized by an uncomfortable sensation of upward moving gas or air through the abdomen and chest as is typical of many "counterflow" phenomenon in this case specifically known as Running Piglet qi.

As described in the following passage from the Huang Di Ba Shi Yi Nan Jing: "Kidney accumulation is called running piglet. It emits from the lower abdomen and ascends to reach below the heart. It is pig-like in form." This reference to the image of a pig has been discussed by various authors as possibly referring to the sensation felt by the patient as if little pig feet were trotting up and down their abdomen and chest, or that the subjective sensation of panic often experienced along with the physical signs somehow remind one of a herd of nervous, squealing pigs. There is undoubtedly a hysterical, frantic quality to much of the symptomology that defines this syndrome. In fact, as I will suggest later, many of the Western correlates to running piglet are psycho-emotional in nature.

We also find internal medicine references from classical herbal texts such as this from the Shang Han Za Bing Lun: "The master said: ‘Ben Tun syndrome starts from the lower abdomen and rushes upward to the chest and throat. The attack is very serious and causes the patient unbearable suffering with a feeling that she might die. Fortunately, the symptoms will gradually reduce and subside. The cause of this syndrome is due to fright and terror' ". This passage mentions not only the trajectory of the counterflow sensation but also its intensity, suggesting that the abiding subjective experience is one of abject panic with a genuine sense of impending doom or death. This, in fact, correlates closely with patient reports of some of the symptoms of Panic Attack as defined in the DSM-IV diagnostic criteria. Indeed, experiencing a panic attack "is said to be one of the most intensely frightening, upsetting, and uncomfortable experiences of a person's life". The kind of somatic and cognitive symptoms associated with this disorder, as with running piglet, are intense, often random and abrupt, but always frightening and incapacitating, often resulting in admissions to the ER (even though they are usually short-lived and far from life-threatening).

The text attributes Ben Tun to "fright and terror", which amongst the correspondence theory of the Five Phases are said to "scatter" the qi of the Kidney and Heart, causing disharmony between Fire and Water. Certainly this is one way to understand the manifesting signs and symptoms of running piglet. Another is to realize that mistreatment

(iatrogenesis) may provoke improper movement of the qi, causing counterflow as the following passage suggests: "When red-hot needling (is used to) cause sweating, the needling site contracts cold, and if a red node forms, (the person) will develop running piglet," Here the text points to the role of pathogenic cold in distorting the normal flow of qi once it enters the body, in this case as a result of improper needling, leading to counterflow problems.

The text gives another example of mistreatment leading to running piglet: "When, after sweating has been promoted, the person has palpitations below the umbilicus about to become running piglet, Fu Ling Gui Zhi Gan Cao Da Zao Tang governs." Here, the implication for the cause of running piglet is damage to Heart Yang due to improper sweating or other precipitation. When, as a result, Heart Yang fails to contain Kidney water, there will be improper movement of pathogenic water in the interior, signified by pulsations below the umbilicus causing running piglet qi.

I find these early references to running piglet significant as they derive from both acupuncture and herbal texts of the Han Dynasty (202 BCE - 220 CE), arguably one of the most influential periods in Chinese medical history. Since the literary and clinical traditions of the various branches of Chinese medicine, though related in many aspects, have nonetheless evolved in their unique and distinct ways, we may assume that these common references to running piglet across different clinical disciplines point to the frequency with which it was encountered in the population at the time. In this article it is my assertion that the disorder is as commonplace today as it was then, notwithstanding the different names by which it is known in contemporary clinical terms, as I have mentioned.

Physical Findings

In terms of abdominal patterns related to running piglet, it is common to both observe and feel pulsations (Fig.1) anywhere along the midline of the abdomen between the pubic bone and the zyphoid process, and the area around Ren 14/15 can often be swollen or raised, a probable symptom of Renmai Repletion. On palpation, the area between Ren 9 and Ren 15 often feels extremely tight and is uncomfortable to the patient. Such tension in the superficial portions of the fascia may relate to repletion in the Tendino-muscular channel of the Heart, whose trajectory moves through this area. There is also the possibility of accumulation in the Liver channel as it disperses through the intercostal regions, giving rise to findings such as hypochondriac and epigastric tightness and resistance (see figs.2 & 3).

There will be a tendency in some patterns of running piglet, where pathogenic water is present, for confirming the Epigastric Splash Sound (see fig.4) upon percussion of the upper left quadrant of the abdomen. Additionally, there may be a deep emptiness palpated on the midline between the navel and the pubic bone (see fig.5) reflecting Kidney depletion. On the pulse, there is often a hurried quality, whilst there may be a wiriness, especially in the third position (Kidney). The cun positions may be weak (Heart and Lung). The right guan (Spleen & Stomach) may be soft and big.

Conclusion

The above passages go some way to explaining the origin, nature, and manifestations of Running Piglet Syndrome. From a psycho-emotional perspective, the primary cause of running piglet clearly involves trauma of one kind or another and, thus, the primary mechanism of counterflow occurs within the Shaoyin and its related orbit (including Chongmai & Renmai). In terms of a Zang-Fu perspective, the Heart and Kidney relationship seems most affected, whereby depletion of Heart Yang Qi (from sweating, cold damage or shock) fails to control Kidney Water Qi, which may then run counterflow.

Equally, Kidney Yang Qi may be damaged (by cold, taxation fatigue, or fright) with the same resulting counterflow pattern. In a similar pattern, Spleen and Stomach Yang Qi may also be damaged (by cold environment or diet, obsessive-compulsive thinking & behavior), impairing transformation of fluids leading to their counter flow. Conversely, patterns of both depletion and repletion in the Liver can illicit counterflow such as Liver Yin Insufficiency or qi constraint leading to Fire rising.

Differential diagnosis in both Chinese and Western medicine, as well as treatment strategies will be the focus of both the workshop in the fall and the articles I am currently working on. In particular, I will be discussing Kanpo approaches to evaluating running piglet from a qi, Blood, and Fluid perspective as well as acupuncture, Kanpo and Shiatsu treatment protocols. OM